Understood Care
Health insurance words can feel like a foreign language. When you know what your plan pays and what you owe, you can plan ahead, avoid surprises, and feel confident at check-in and at checkout. If you are managing Medicare or a Medicare Advantage plan, a few basics go a long way: what your deductible is, how copays and coinsurance work, and why the Medicare-approved amount or contracted rate matters more than the number on a bill.
This article explains those terms using reliable, noncommercial sources and brings the video guidance to life. You will also see exactly how an advocate can compare your bills with your insurance statements, contact the office on your behalf, and help get incorrect balances adjusted.
If you prefer hands-on support at any point, an advocate can help you analyze bills, coordinate care, and schedule appointments.
Your deductible is the amount you pay each year before your plan starts sharing costs for covered services. In Original Medicare Part B, the standard annual deductible is set by the federal government and can change every year. After you meet the deductible, Medicare usually pays 80 percent of the Medicare-approved amount for most Part B services and you pay 20 percent as coinsurance.
A copay is a set dollar amount you pay for a service. Many Medicare Advantage plans use copays for office visits. For example, your primary care visit might be 0 dollars, 10 dollars, or 20 dollars depending on your plan.
Coinsurance is a percentage of the allowed or approved amount that you pay after the deductible. With Original Medicare Part B, the common split is 80 and 20. Medicare pays 80 percent of the approved amount and you pay 20 percent. Some services have different cost sharing rules, and preventive care may be fully covered.
Providers submit a billed charge that can look very high. Your plan uses an allowed amount or contracted rate. You are never responsible for paying 20 percent of the billed charge in Original Medicare when the provider accepts assignment. You pay your share of the Medicare-approved amount instead. For Medicare Advantage, the plan’s contracted rate applies. The difference between the billed charge and the allowed amount is adjusted off for participating providers.
After a claim is processed, you receive an Explanation of Benefits from your health plan or a Medicare Summary Notice for Original Medicare. These are not bills. They show what was billed, what the plan allowed, what the plan paid, and the maximum you may owe the provider. Comparing these notices with any bill you receive is one of the fastest ways to catch errors.
Original Medicare is often described as an indemnity style plan. For most Part B services after you meet your deductible, Medicare pays 80 percent of the Medicare-approved amount and you pay 20 percent. The approved amount comes from Medicare fee schedules. If your doctor accepts assignment, they agree to take the approved amount as payment in full. That means you owe only your deductible and coinsurance based on that approved amount. You do not owe the difference between the billed charge and the approved amount for participating providers.
If a provider does not accept assignment, special rules apply and the provider may be able to charge a limited extra amount. This is uncommon with many routine services but is important to ask about before a visit.
Medicare Advantage plans are offered by private companies approved by Medicare. They bundle Part A and Part B, and many include Part D drug coverage. Instead of the standard 80 and 20 split on the Medicare-approved amount, many services use fixed copays, and some services use coinsurance. Plans can also have deductibles for certain services and an out-of-pocket maximum for in-network care, which Original Medicare does not have on its own.
Because each plan sets its own copays, coinsurance, referral rules, and network, it helps to check your plan details before tests or procedures. You can call the plan, sign in to the plan’s member portal, or let an advocate do this and translate the results into clear next steps.
The video highlighted common pain points and how an advocate can help. Here is how that looks step by step.
Several protections limit surprise out-of-network bills for certain situations, such as most emergency care and some services at in-network hospitals. These protections do not cover every scenario. The best prevention is to confirm network status and obtain estimates when possible. If you receive a bill that seems wrong, contact your plan and the provider promptly, and loop in an advocate who can help escalate and resolve disputes.
You do not have to do this alone. If you want one-to-one help, start with Analyze Bills or Care Coordination.
A deductible is the amount you pay for covered services each plan year before the plan starts sharing costs. For Original Medicare and most Medicare Advantage plans, the deductible resets on January 1 each year. Plan documents and CMS fact sheets show the specific dollar amounts for the current year.
A copay is a fixed dollar amount you pay for a service. Coinsurance is a percentage of the approved or contracted rate that you pay after the deductible. Many Medicare Advantage plans use copays for office visits and coinsurance for hospital or outpatient services. Original Medicare Part B commonly uses 20 percent coinsurance after you meet the deductible.
This is the amount Medicare sets as payment for a covered service. If your provider accepts assignment, they agree to this approved amount as payment in full. Medicare pays its share and you pay your share based on that amount, not on the provider’s billed charge.
No. An EOB or a Medicare Summary Notice explains what was billed, what the plan allowed, what the plan paid, and the maximum you may owe the provider. Use it to check any bill you receive for errors.
Confirm that the facility and all clinicians are in network, ask whether prior authorization is required, and request a written estimate with codes before your visit. If you receive a bill that does not match your plan’s allowed amount or your EOB, contact the provider and your plan. An advocate can do this with you or for you.
Medicare Advantage plans bundle Part A and Part B and often Part D. They set copays and coinsurance, use provider networks, and include an annual out-of-pocket maximum for in-network care. Original Medicare typically uses the 80 and 20 split after the Part B deductible, does not have an out-of-pocket maximum on its own, and does not use networks, though accepting assignment matters for your costs.
Yes. We can call your plan or use the plan portal to confirm your benefits for the specific service and location. We translate the information into plain language so you know what to expect and what questions to ask.
You can start with Analyze Bills or Care Coordination at any time.
This content is educational and is not a substitute for medical advice. Always consult your healthcare provider for personalized care.
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